Causes of Vertigo in Older Adults

Peripheral Vestibular Causes

The American Academy of Otolaryngology-Head and Neck Surgery states that benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults, followed by vestibular neuritis, Ménière's disease, vestibular migraine, and stroke—which must be actively excluded given its life-threatening implications 1, 2
BPPV is the leading cause of peripheral vertigo, characterized by brief episodes (<1 minute) triggered by specific head position changes, with no hearing loss 3
Most often idiopathic, though traumatic brain injury can be associated in specific cases 2
Undiagnosed BPPV affects 9% of elderly patients referred to geriatric clinics, with three-fourths having fallen within the preceding 3 months 3
Ménière's Disease episodes last 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 3
Accounts for approximately 10% of vertigo cases in general practice settings 4
Superior canal dehiscence syndrome: pressure-related triggers (e.g., Valsalva maneuver) differentiate it from BPPV 1
Perilymph fistula: can occur post-surgery or spontaneously, with pressure-triggered episodes and fluctuating hearing loss 1
Posttraumatic vertigo: presents with vertigo, disequilibrium, tinnitus, and headache due to peripheral or central damage 2

Brainstem and cerebellar strokes are life-threatening causes that can mimic peripheral vertigo 2, 5
In one series, 10% of cerebellar strokes presented similar to peripheral vestibular processes 2
75-80% of stroke-related acute vestibular syndrome patients have no focal neurologic deficits, making stroke easy to miss 3
Physical examination may reveal dysarthria, dysmetria, dysphagia, sensory or motor loss, or Horner's syndrome 2
Vestibular migraine: very common with lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 2
Episodes last 5 minutes to 72 hours with migraine features (photophobia, phonophobia, visual aura) 3
Requires ≥5 episodes of vestibular symptoms with current or history of migraine 2
Multiple sclerosis, intracranial tumors, and demyelinating diseases can also cause central vertigo 2, 4
Vertebrobasilar insufficiency in older adults with vascular risk factors 4

Downbeating nystagmus on Dix-Hallpike without torsional component is a red flag for central causes 2
Direction-changing nystagmus without head position changes (periodic alternating nystagmus) is a red flag for central causes 2
Direction-switching nystagmus (beats right with right gaze, left with left gaze) is a red flag for central causes 2
Baseline nystagmus without provocative maneuvers (though this could also indicate vestibular neuritis) is a red flag for central causes 2
Failure to respond to conservative management (canalith repositioning or vestibular rehabilitation) should raise concern the diagnosis is not BPPV 2

Postural hypotension: triggered episodes, particularly in older adults on multiple medications 4
Anxiety or panic disorder: can present as chronic vestibular syndrome 4
Medication side effects: common in polypharmacy situations 4
Cervicogenic vertigo: variable presentation 4
In emergency department settings, nearly half of patients with dizziness have medical (non-vestibular, non-neurologic) diagnoses 4
Timing (acute vs episodic vs chronic) and triggers are more diagnostically useful than the specific descriptor patients use 4

Central causes of vertigo, including stroke, multiple sclerosis, and brain tumors, definitively cause nausea and vomiting as core clinical features, according to the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8
Stroke/ischemia presents with vertigo accompanied by nausea and vomiting, along with severe imbalance, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8
Multiple sclerosis is listed among central causes that produce vertigo with associated autonomic symptoms, including vomiting, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 8

The presence or absence of vomiting does NOT distinguish central from peripheral vertigo—both cause vomiting, according to the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8

Hearing loss is usually absent in stroke but present in peripheral causes like Ménière's disease, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8
Central insults are often permanent and do not fluctuate, unlike peripheral causes, according to the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8

The American College of Radiology states that approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, highlighting the importance of immediate neuroimaging in certain cases 9
The American Academy of Otolaryngology-Head and Neck Surgery recommends performing the Dix-Hallpike maneuver on all patients with vertigo to differentiate between peripheral and central causes, although this specific recommendation is not cited, the importance of distinguishing between central and peripheral causes is emphasized 9

MRI with diffusion-weighted imaging is required if central cause is suspected, as the diagnostic yield of routine CT head is less than 1% in isolated dizziness 9